Tasew et al. BMC Res Notes (2019) 12:612 https://doi.org/10.1186/s13104-019-4661-x RESEARCH NOTE Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia Hagos Tasew * , Teklewoini Mariye and Girmay Teklay Abstract Objective: The objective of this study was to investigate documentation practice and factors affecting documenta- tion practice among nurses working in public hospital of Tigray region, Ethiopia. Results: In this study, there were 317 participants with 99.7% response rate. The result of this study shows that practice nursing care documentation was inadequate (47.8%). Inadequacy of documenting sheets AOR = 3.271, 95% CI (1.125, 23.704), inadequacy of time AOR = 2.205, 95% CI (1.101, 3.413) and with operational standard of nursing documentation AOR = 2.015, 95% CI (1.205, 3.70) were significantly associated with practice of nursing care docu- mentation. To conclude, more than half of nurses were not documented their nursing care. Employing institutions should provide training on documentation of nursing care to enhance knowledge and create awareness on nurses’ documentation to nursing directors and chief executive officer to access adequate documenting supplies besides employing more nurses. Keywords: Practice, Documentation, Nurses, Associated factors © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Introduction Nursing documentation is the record of nursing care that is planned and delivered to individual patients by quali- fed nurses or other caregivers under the direction of a qualifed nurse [1]. Nursing documentation is the princi- pal clinical information source to meet legal and profes- sional requirements [2]. It is a vital component of safe, ethical and efective nursing practice whether done man- ually or electronically [3]. Nursing documentation should fulfll the legal requirements of nursing care documenta- tion [4]. According to a survey done by WHO it has been shown that poor communication between health care profes- sionals is one factor for medical errors [5]. Tere are also evidence indicating that nursing documentation has relationship with patient mortality [6]. Although keep- ing a patient record is part of their professional obliga- tion, many studies identifed defciencies in practice of documentation among nurses across the globe [7, 8]. It has been reported that nursing records are often incom- plete [8, 9], lacked accuracy and had poor quality [10, 11]. Te challenges for documentation reported so far, include shortage of staf [12, 13], inadequate knowledge concerning the importance of documentation [12–15], patient load [12, 14], lack of in-service training [14, 15] and lack of support from nursing leadership [12]. As a remedy for these, many researchers recommended to use a multidisciplinary approach like to develop poli- cies and guidelines on nursing care documentation [12, 13, 15] and provide sustained continuing training oppor- tunities for nurses on efectiveness of documentation [7, 12, 13, 16, 17]. Te nursing leaders are also expected to support, motivate [12, 17] and increase the number of stafs [15] for a better documentation practice. Studies from South Africa and Ugandan reported defciency in attitudes, knowledge and practice behav- iors [17, 18]. Te studies done in Kenya and Ghana also evidenced lack of standardized method and insufcient information of nursing documentation [12, 13]. In Ethio- pia, inadequacy of data collection with lack of quality was Open Access BMC Research Notes *Correspondence: tasewh2@gmail.com Department Nursing, College of Health Science, Aksum University, Aksum, Ethiopia